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Cbt 2014

  1. 1. Using Cognitive Behavioral Therapy to Improve Treatment Outcomes in SUD Treatment Developed and Presented by: Roland Williams, MA, LAADC, NCACII, CADCII, SAP President and CEO, Free Life Enterprises www.rolandwilliamsconsulting.com
  2. 2. Class Introductions • Who you are • What you do • What are your goals for today’s training • How would you rate your clinical skills on a scale of 1-10 • Your most memorable experience in your work • Something about yourself you don’t normally tell people • One word that best describes you right now
  3. 3. What is CBT?
  4. 4. A Theory That Works • If you change the way you think • You can change the way you feel • If you change the way you feel • You will change the type of urges you have • If your urges change • Your actions will be change • If your actions change • Your consequences will change
  5. 5. Cognitive Therapy Principles • Thoughts lead to feelings • Feelings lead to urges • Urges lead to action • Action leads to consequences
  6. 6. T,F,U,A,C’s
  7. 7. Listening To Your Head • Our head can be a dangerous place, we often have patterns of self defeating thoughts that lead us to bad feelings and subsequently bad decisions. Remember, thoughts lead to feelings, feelings lead to urges and urges lead to actions, and actions have consequences both good and bad. • If we can learn to identify when a thought is distorted, we can correct it or redirect in in such a way that the chances of bad feelings and actions are minimized.
  8. 8. Internal Dialogue My Stinking Thinking My sane thinking My committee My conscience My old tapes My recovery tools My addict voice My Recovery self My lower power My Higher Power My rat brain My God brain My dark side My light side Mr. Hyde Dr. Jekyl Negative self talk Positive self-talk COGNITIVE DISTORTION RATIONAL RESPONSE
  9. 9. Cognitive Distortions • Overgeneralization • Labeling • Disqualifying the positive • Jumping to conclusions • Emotional reasoning • Mental filter • Minimizing and maximizing • All or nothing thinking • Personalizing • Should statements
  10. 10. • All-or-nothing thinking: You see things in black and white categories. If your performance falls short of perfect, you see yourself as a total failure. • Overgeneralization: You see a single negative event as a never-ending pattern of defeat. • Mental filter: You pick out a single negative detail and dwell on it exclusively so that your vision of all reality becomes darkened, like the drop of ink that discolors the entire beaker of water.
  11. 11. • Magnification (catastrophizing) or minimization: You exaggerate the importance of things (such as your goof-up or someone else's achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or the other fellow's imperfections). This is also called the "binocular trick.” • Emotional reasoning: You assume that your negative emotions necessarily reflect the way things really are: "I feel it, therefore it must be true.” • Personalization: You see yourself as the cause of some negative external event for which, in fact, you were not primarily responsible.
  12. 12. • Should statements: You try to motivate yourself with shoulds and shouldn’t, as if you had to be whipped and punished before you could be expected to do anything. "Musts" and "oughts" are also offenders. The emotional consequence is guilt. When you direct should statements toward others, you feel anger, frustration, and resentment. • Labeling and mislabeling: This is an extreme form of overgeneralization. Instead of describing your error, you attach a negative label to yourself: "I'm a loser." When someone else's behavior rubs you the wrong way, you attach a negative label to him, "He's a damn louse." Mislabeling involves describing an event with language that is highly colored and emotionally loaded.
  13. 13. • Disqualifying the positive: You reject positive experiences by insisting they "don't count" for some reason or other. You maintain a negative belief that is contradicted by your everyday experiences. • Jumping to conclusions: You make a negative interpretation even though there are no definite facts that convincingly support your conclusion. – Mind reading: You arbitrarily conclude that someone is reacting negatively to you and don't bother to check it out. – The Fortune Teller Error: You anticipate that things will turn out badly and feel convinced that your prediction is an already-established fact.
  14. 14. Triple Column Technique Automatic Self Talk Cognitive Distortion Rational Response He is an ass and a control freak. He never liked me and always tries to humiliate me. I’m never going to finish this program. I’m an addict and will always be one. I’m going to fail this program just like the last. The rest of the group thinks I’m weak now. I talk to much and will never say another word. I should just leave now, its not going to get better. Labeling and mislabeling Emotional reasoning All of nothing thinking Mind reading Fortune telling Mind reading Overgeneralization Maximizing and minimizing Disqualifying the positive Should statement Fortune telling He’s been cool with me and is just doing his job. This is the first time I ever felt humiliated by him. Maybe this is my stuff. If I hang in there I know I can finish. This program is nothing like the last one, and I’m not the same guy I was then. Actually many group members said I handled it well. I was trying to help and will not give up. I know I can make it better. Offending incident: Counselor confronted me in group when I offered advice
  15. 15. CBT and Group Therapy
  16. 16. Group Dynamics • Beginning – Practice opening exercises • Middle – How to use the time • End – Closure exercise
  17. 17. Johari Window Open to you and others Open to you Open to others Closed to you and others
  18. 18. AA compared to Therapy Group • Abstinence • The how of Recovery • Opening Rituals • Sharing story • No cross-talk • Focus on 12 Steps • No leaders • Don’t take inventories • Focus on own issues • T. F.U.A’s • The why of Recovery • Opening Rituals • Self disclosure • Encourage cross-talk • Focus on process • Facilitated • Give direct feedback • Willing to confront others
  19. 19. Benefits of Group Therapy • Group counseling is often more effective than the individual approach because: • Group members can practice new skills needed every day. • There is the benefit of feedback and insight of other members. • The group can model real life relationships. • Members can learn how to cope with problems by observing others. • Practical advantages, such as costs and time economy. • Ideally use a combination of group and individual therapy.
  20. 20. Types of Groups
  21. 21. Problem-Solving Process Group • Process group is the group in which clients build their communication and problem solving skills. There is no pre- determined topic. Facilitators guide the group to help them: • Understand their problem more clearly; • Learn the steps of problem solving in a safe, supportive, respectful environment; • Identify and change: mistaken thinking, unmanageable feelings, urges to do things that make life more painful, self- defeating behaviors and relationships that make problems worse; • Be listened to, taken seriously, respected and affirmed; • Tap into the group conscience, a powerful source of knowledge, courage, strength and hope in personal problem solving.
  22. 22. Focused Work Group • These are topic-driven workgroups. • Core assignments are addressed here such as: Recovery Plans (treatment goals), First Step presentations and Exit Plans. • Individualized assignments may also be presented. • Other topics are diverse and reflect the needs of the current population as well as the specific talents of the facilitator (e.g., communication skills, grief and loss). • These groups are highly interactive, stressing peer feedback.
  23. 23. Psycho-Education Group Educational groups or lectures are didactic and participative. Core topics may include: • The disease of addiction • Medical aspects, • Relapse dynamics, • Introduction to the 12 steps • Anger management, and • Practical application of recovery principles.
  24. 24. Tips for the Facilitator The group is the client You don’t have to be right Avoid Dyads Use the Group If you’re doing most of the talking, something’s wrong Don’t pontificate Be careful with self-disclosure Don’t participate in exercises Get the group grounded, centered Watch for non-verbal communication Let silence be okay Comfort is not the goal Let people cry, vent, and/or be angry Be on time Make eye contact Use I statements Don’t open something you can’t close by end of the group Trust you instincts Don’t portray your opinions as facts Don’t be a bully Avoid leading questions Never sit next to a co-facilitator Don’t allow spectators in the group, make them participate Bring everyone into the discussion Resist the urge to ‘fix-it’ Don’t play favorites Don’t allow scapegoats
  25. 25. Tips for the Facilitator, cont. Convince the group the power is in the group, not the facilitator Don’t manipulate the group to take your side Don’t punish group members for confronting, challenging, or disagreeing with you Don’t take responsibility for group member recovery Confront inappropriate behavior as it occurs Insist that group members talk directly to each other, not about each other Respect group member’s boundaries Ask one question at a time Pay attention to group members stress level Pay attention to your stress level Teach the group how to confront each other, don’t be the only one who does it Pay attention to when people need to leave the group Explain the group process to each new member before they begin
  26. 26. Client Specific Issues
  27. 27. Challenging Clients • The Dominator • The Hider • The Bully • The Know-it-all • The Junior Therapist • The Super-Grouper • The Cry-Baby • The Rescuer • The Outlaw
  28. 28. Coping Mechanisms • Acting out: not coping - giving in to the pressure to misbehave. • Aim inhibition: lowering sights to what seems more achievable. • Attack: trying to beat down that which is threatening you. • Avoidance: mentally or physically avoiding something that causes distress. • Compartmentalization: separating conflicting thoughts into separated compartments. • Compensation: making up for a weakness in one area by gain strength in another. • Conversion: subconscious conversion of stress into physical symptoms. • Denial: refusing to acknowledge that an event has occurred. • Displacement: shifting of intended action to a safer target. • Dissociation: separating oneself from parts of your life. • Fantasy: escaping reality into a world of possibility. • Idealization: playing up the good points and ignoring limitations of things desired. • Identification: copying others to take on their characteristics.
  29. 29. Coping Mechanisms, cont. • Intellectualization: avoiding emotion by focusing on facts and logic. • Introjection: bringing things from the outer world into the inner world. • Passive aggression: avoiding refusal by passive avoidance. • Projection: seeing your own unwanted feelings in other people. • Rationalization: creating logical reasons for bad behavior. • Reaction Formation: avoiding something by taking a polar opposite position. • Regression: returning to a child state to avoid problems. • Repression: subconsciously hiding uncomfortable thoughts. • Somatization: psychological problems turned into physical symptoms. • Sublimation: channeling psychic energy into acceptable activities. • Suppression: consciously holding back unwanted urges. • Symbolization: turning unwanted thoughts into metaphoric symbols. • Trivializing: making small what is really something big. • Undoing: actions that psychologically 'undo' wrongdoings for the wrongdoer.
  30. 30. Stages of Change • Pre-Contemplation • Contemplation • Preparation • Action • Maintenance
  31. 31. Developmental Model of Addiction • Experimentation: Social use, I can take if or leave it, I have no problems • Situational misuse: Drugs and alcohol make me a better man in certain situations • Problem use: I use to cope with everyday life issues, and I’m having problems • Dependence: I continue to use despite known negative consequences, loss of control, blackouts, tolerance and withdrawal, lots of problems
  32. 32. Developmental Model of Recovery • Transitional: I have a problem but I can control it. • Stabilization: l can’t control d/a and I need to learn how to not use • Early recovery: Change playmates, playgrounds and playthings • Middle recovery: Balance • Late recovery: Deal with unresolved childhood issues • Maintenance: Continue to nurture bio-psycho-social and spiritual growth
  33. 33. Utilizing Cognitive Therapy Techniques in Group
  34. 34. Cultural Considerations
  35. 35. Improving Communication Across Cultural Boundaries • Recognize differences • Build Your Self-Awareness • Active listen, then interpret • Don’t assume your interpretation is correct • Verbalize your own non-verbal signs • Share your experience honestly • Acknowledge any discomfort, hesitation, or concern • Practice politically correct communication • Give your time and attention when communicating • Don’t evaluate or judge
  36. 36. Cultural Adaptation Styles Integration Model Dominant Minority X X X X
  37. 37. Recovery Grid Biological Psychological Social Spiritual 19 15 22 14
  38. 38. Bio-Psycho-Social-Spiritual: Cultural Challenges • Biological: – lack of access to medical care – distrust of medical providers – cultural healing practices – culturally related illnesses – culturally related diet considerations
  39. 39. Bio-Psycho-Social-Spiritual: Cultural Challenges • Psychological – low self esteem – feelings of inadequacy – pessimism – suspicion and distrust – depression – reluctance to seek therapy – feeling different or excluded
  40. 40. Bio-Psycho-Social-Spiritual: Cultural Challenges • Social – high risk living situations – drug infested neighborhoods – marketing strategies targeting minorities – friends don’t always support positive change – family beliefs about using/ seeking help – community/extended family support
  41. 41. Bio-Psycho-Social-Spiritual: Cultural Challenges • Spiritual – Spiritual values in conflict: shame/guilt – church support systems – AA conflicts with religious beliefs – Spiritual rituals that involve use of drugs or alcohol
  42. 42. Bio-Psycho-Social-Spiritual Cultural: Cultural Challenge • Give to your community • Spend time with your children • Talk up not down to your people • Patronize your peoples business • Subscribe to your cultures publications • Give to culturally friendly charities • Study your history • Teach your history • Be a positive role model
  43. 43. Closure Exercise • Who or what stood out for you most today, explain your answer to the group • What if anything are you going to do different in your work.